Metamorphosis of
Association to College

Dr Thomas Bewley,
Past-President of the Royal College of Psychiatrists and Mrs
Vanessa Cameron, Chief Executive

The fortieth anniversary of the Royal College
of Psychiatrists (RCPsych) is an appropriate time to reflect on the
past. The Royal
Medico-Psychological Association (RMPA) was not moribund in
1972 but its functions were limited. It had regional
divisions in the UK and Ireland and two specialist sections (mental
handicap and child psychiatry). It had one of the best
psychiatric journals in the world. The RMPA had little input into
teaching, research or academic psychiatry and had no examination to
become a member.There was inadequate training for junior
psychiatrists in the1950’s or 1960’s, except at the Institute of
Psychiatry in London as well as some in Edinburgh and Dublin.
Much education was “sitting by Nellie”: watching and copying
the behaviour of a Consultant, for whom a trainee was working as a
registrar in a mental hospital. They were fortunate if the
first psychiatrist they worked for was enthusiastic, competent,
knowledgeable and a good role model.

In the 1950’s and 1960’s Government
departments still took much of their psychiatric advice from the
Psychological Medicine Committee of the Royal College of Physicians
(RCP). This consisted of Consultant Psychiatrists who had
passed the MRCP examination. When a proposal to turn the RMPA
into a College was first mooted, this committee was against it. At
a later date they changed their views and supported the idea of the
new College. This was a major change as many academic
psychiatrists thought the RMPA was no more than a club for Medical
Superintendants.

The first records of the RMPA considering
becoming a College occurred in the 1950’s when it was occasionally
discussed at Council meetings, but no action was taken. A
pressure group (the Society for Clinical Psychiatrists: originally
founded to replace Physician Superintendants with Consultants)
raised the matter at the RMPA’s Annual General Meeting in1964, when
a proposal that the RMPA should petition to become a College was
passed by 150 votes to 9. Their earlier postal ballot had
shown that 75% of the membership favoured this development.

Before 1970 there had been little attempt by
University teaching departments to provide input (apart from some
lectures) into the education of junior psychiatrists in mental
hospitals and other isolated units. Many trainees in
psychiatry were unhappy about the proposed new College as they
believed little would be done about their professional education
and development. They expected the proposed new examination
for membership would be modelled on the examinations of the other
Royal Colleges. They feared it would be difficult to pass,
with fees for the examination going to the College coffers for the
other purposes than education and training. This led to the
formation of another pressure group, the Association of
Psychiatrists in Training (APIT), with 600 members who pressed for
education and training to be included in the new Charter and for
the examination to be scrapped and replaced by continuous
assessment/monitoring. APIT was very active from 1968 to 1972
and were able to insert the responsibility for Education and
Training into the proposed new Charter. At the time of the
inception of the College, they recommended that all its members
should boycott the new examination.

Following two years of acrimonious debates
about the future College, there was an election of Officers and
Council. Two- thirds of the Council were new, as were most of the
Officers.There were representatives from all regions and
specialities, with equal numbers of Fellows and Members. There
were two Affiliate members, one a trainee (who was rapidly co-opted
to Council). Following alterations to the original proposed
Charter, the College was allowed a small role for Inceptors (the
constitutional name for trainees) for an experimental ten-year
period. Junior psychiatrists in training posts were rapidly
co-opted on to virtually all committees, though initially there was
no official role for them. The new College played the rules
according to the game rather than the other way round. The
trainee was co-opted as a “non-voting participant observer”,
appointed from an invented special subcommittee of the Education
Committee with trainees from all regions and specialities. The
introduction of trainees into all College activities was successful
and led to a review of the Charter to make trainees an integral
part of the College. This innovation was later followed by
other Colleges.

In its first twenty years the College was
defining its roles. The Officers were concerned with developing
satisfactory training schemes.Three areas concerned the
Officers:

developing a new examination (the
MRCPsych)

establishing a system of inspection and
accreditation of all training schemes, which was started by the
first Deans

ensuring a place for trainees in all College
structures.

The new examination proved less formidable
than originally feared, and those who had passed a DPM were
exempted from all parts, except the final viva, and the majority
passed this. Although few people sat the first examination,
nine out of the 10 passed and several hundred sat the next
ones.

The College had also been given the
responsibility to inspect and approve training posts.The Dean
started the overview of training posts with teams in all regions
inspecting the posts in other Regions. A convenor visited all posts
with two colleagues. After a short time it became mandatory that
one of these was a trainee (a Senior Registrar who had passed the
MRCPsych).

There were few adequate training schemes that
could be accepted for the following five years and the majority
were only accredited for one year. This changed as pressure from
the new College led to amalgamations into bigger training schemes
and eventually into Regional ones. Trainees started to rotate
between units with the opportunity to work with a different range
of consultants and academic staff so that they would acquire their
own style of working from the best people. The inspections
were successful since the College had the power to cease
recognising posts if there was an inadequate educational input,
such as no lectures, no other teaching, no library facilities, no
Clinical Tutor nor any relationship with the Postgraduate Dean.
There was also the development of a new and acceptable
examination.

There was a need for more staff to deal with
these new responsibilities and four staff in three rented
rooms in 1972 soon became inadequate. A new headquarters was
obtained in Belgrave Square, which was enlarged in 1985 to house
the growing Publications Department and a new Research Unit. These
later expanded leading to the need to lease further premises. The
College now has 200 paid staff housed in Belgrave Square, Aldgate
East, London and in offices throughout the United Kingdom.

The number of members of the RMPA in 1952
when the idea of a College was first mooted was 1,242. In
1972 there were 4,700 members and Associates. The numbers have
continued to grow throughout the whole life of the College. There
were 8,177 members and Associates in 1992, and 15,860 at the
beginning of 2012.

A sporadic memorandum headed Notes and News
was developed into a monthly called News and Notes. The
later became a refereed journal the Psychiatric Bulletin,
now
The Psychiatrist, and further journals and books were
added when the College developed its own professional publishing
department in the 1980’s. This Department now produces four
scientific journals and about twelve books annually.

Another major development was the
establishment of the Research Unit in 1989. The proposal to
have such a Unit was not popular with University Departments of
Psychiatry, but sufficient funds were collected from the membership
to establish it at 17 Belgrave Square where further space was
available after significant rebuilding. The Unit focussed on
those areas that could not easily be carried out by either the
Department of Health or individual University Departments. This
Research Unit has now evolved into the College’s Centre
for Quality Improvement and the National Collaborating Centre for Mental
Health and both parts are housed in a separate building in
Aldgate East, London.

There have been changes in public attitudes
towards mental illness and psychiatry over the last forty years,
with greater knowledge by the public and more acceptance of the
advantages of treatment, both psychological and pharmacological for
the mentally ill. Some high-profile individuals are more
willing to admit to having certain mental illnesses, but people
still remain wary about making it known that they have a relative
with a serious psychosis. Tuberculosis and cancer were once
rarely mentioned though they are now more freely disclosed by those
with these conditions. This is not yet the case with the
majority of the more serious mental illnesses.

The College has organised five public education campaigns. The first
launched jointly with the Royal College of Practitioners in 1992
was called “Defeat Depression” and led to an increase in the early
detection of depression by general practitioners in the UK, with
more prescribing of antidepressant drugs and more awareness of
the role of Cognitive Behavioural Therapy in the treatment of
depression. The second anti-stigma campaign was launched in
1998 and was “Changing Minds” and this had some modest
success. The campaign led to a similar initiative by the
Department of Health and some major mental health charities and
this is ongoing.

The College has been more proactive in both
policy matters and politics. The input to Government from the
College in the run up to the new Mental Health Act (1983) was far
greater than the Association’s input to the 1959 Act; at a time the
Government of the day relied heavily on the Royal College of
Physicians rather than the RMPA. The College also became
concerned with the world-wide misuse of psychiatry by governments
(particularly the Soviet Union, but also South Africa, Romania and
China) to incarcerate dissidents in mental hospitals rather than
gulags.

The RMPA had seen itself as an organisation
representing psychiatry in the whole of the British Empire and had
been anxious to develop colonial branches, though attempts to set
up overseas divisions generally foundered. Council decided in 2000
that the College should become more active in strengthening its
international activities and it created International Divisions based on the WHO
geographical divisions. It organised elections for Chairs and
other Officers and had annual meetings with these
representatives.

A new journal, International
Psychiatry, was started in 2003. The College’s
Honorary Fellows set up a fund to enable psychiatrists working in
low and middle income countries to attend the College’s
International Congresses. The College had 2,700 overseas
members in 2012. The RMPA had an Irish Division covering
the whole of Ireland and had equal numbers of officers from both
the South and the North. The Irish Division continued in this
format until it divided into two separate divisions – the Irish
Division and the Northern Irish
Division. In 2009 the Irish Division metamorphosed into the
College of Psychiatry in Ireland which publishes the “Irish Journal
of Psychological Medicine”. Irish trainees continue to take
and pass the MRCPsych examination.

The world-wide move to continue closing large
mental hospitals continued through the whole of the College’s first
thirty years. The money saved from the sites of hospitals sold
could have gone to strengthening community care and other
psychiatric facilities, rather than to other parts of the NHS that
politicians and the press considered to be more deserving.
The closure of traditional asylums led to different concerns about
the care and treatment of the mentally ill, particularly from
carers who often found themselves unsupported.

The College started to develop an official
relationship with patients and carers in the present
century. The Service Users
Recovery Forum and the Carers Forum were
established. Patients and carers now participate in all
College activities and are represented on all major
committees. A powerful alliance
between psychiatrists, patients and carers has now been formed
which can be influential when negotiating with the Government.

The College‘s Communications and Policy
Department has produced a wide range of prize-winning information
leaflets and factsheets on all major
psychiatric conditions and treatments. These are produced
online in many languages. The College has put a lot of time
and effort into developing its website and it receives the highest
Google ranking amongst the medical royal colleges with
over 360,000 visits per month. The College has also embraced
social media such as YouTube and
Twitter.

There are many challenges ahead. There is
still too much stigma attached to psychiatric patients and this has
an effect upon the recruitment
into psychiatry. There are insufficient UK medical
graduates choosing to specialise in psychiatry. Research had
shown various reasons for this (“patients are incurable”, “not a
scientific discipline” “no evidence-based research” and “the
profession are stigmatised by other senior doctors”). The
College aims to increase the number of young doctors choosing a
career in psychiatry by 50% (an increase of 200 annually) by
organising summer schools, taster sessions, setting up social
networks, supporting psychiatric societies in medical schools and
giving valuable awards to help fund research electives. The
College is also seeking a new headquarters to house all its
activities, including the Centre for Quality Improvement and the
National Collaborating Centre for Mental Health.

The conversion from an Association to
College was momentous bringing about many changes. Forty
years have seen improvements in the development of proper education
for psychiatrists. The College has developed a closer
relationship between the profession, carers and patients. It
is now the voice of psychiatry in mental health policy, teaching,
clinical work and the care of patients who have some of the most
difficult and intractable illness known to doctors. A “medical
superintendents club” has metamorphosed into a highly respected and
active Medical Royal College.